Pre-Existing Conditions
Under the Affordable Care Act, health insurance companies can’t refuse to cover you or charge you more because you have a “pre-existing condition” (.ie, a health problem you had before the date of your new health coverage starts. They also can’t charge more for women than men.
These rules went into effect for plan years beginning on, or after January 1, 2014.
What This Means for You
Health insurers can no longer charge more, or deny coverage, to you or your child due to a pre-existing health condition like asthma, diabetes, or cancer. They also cannot limit benefits for pre-existing conditions. Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition.
Learn more about coverage for pre-existing conditions.
Grandfathered Health Plan
Grandfathered Health Plans are pre-existing plans used in connection with the Affordable Care Act. They are a group health plan that was created or an individual health insurance policy that was purchased, on or before March 23, 2010. Grandfathered Plans are exempt from many changes required by the Affordable Care Act.
Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers.
A health plan must disclose in its plan documentation whether it considers itself to be a grandfathered plan, and it must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with any questions that arise.
(Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).
Types of Coverage
Bronze Plans
Bronze Plans tend to have the lowest premiums of all Metallic Plans since they are only required to provide 60% of cost-sharing on average. Bronze Plans provide an average cost-sharing value (known as Actuarial Value (AV)) of 60%. This means that a Bronze Plan must cover an average of 60% of all plan enrollees’ covered out-of-pocket costs. This does not mean that 60% of actual costs will be covered for any given person. A small minority of policyholders will account for the majority of costs. So Actuarial Value should be looked at as a sign of how good a plan’s cost-sharing is, not as a literal amount. Literal cost-sharing amounts can be found on a plan’s benefit sheet.
Silver Plans
Silver Plans are the marketplace standard plan. The second-lowest-cost Silver Plan in a state is used as the benchmark plan when determining subsidies. Silver Plans provide an average cost-sharing value (known as Actuarial Value (AV)) of 70%. This means that a Silver Plan must cover an average of 70% of all that plan’s enrollee’s covered out-of-pocket costs (based on a standard population). This does not mean that 70% of actual costs will be covered for any given person. A small minority of policyholders will account for the majority of costs. So Actuarial Value should be looked at as a sign of how good a plan’s cost-sharing is, not as a literal amount.
Gold Plans
Gold Plans provide an average cost-sharing value (known as Actuarial Value (AV)) of 80%. This means that a Gold Plan must cover an average of 80% of all that plan’s enrollee’s covered out-of-pocket costs. This does not mean that 80% of actual costs will be covered for any given person. A small minority of policyholders will account for the majority of costs. So Actuarial Value should always be looked at as a sign of how good a plan’s cost-sharing is, not as a literal amount. In some states Gold plans must meet additional criteria, making the cost-sharing offered on these plans even more attractive.
With better cost sharing, comes higher premiums.
Platinum Plans
Platinum Plans are designed to cover 90% of out-of-pocket costs on average. This is known as having an Actuarial Value (AV) of 90%. This means for a standard population the plan will, on average, cover 90% of all out-of-pocket costs for essential health benefits. This is not the exact amount of cost-sharing your plan will provide you.
Given the generous cost-sharing, Platinum Plans have the highest premiums on average. Not all insurers offer Platinum Plans in the marketplace. Different states may have different rules for what these plans must offer beyond the minimum standards in the ACA.
Catastrophic Health Plans
Catastrophic health plans generally have low premiums, high deductibles, and high cost-sharing amounts. Catastrophic plans will not typically pay any out-of-pocket costs like copays and coinsurance. Deductibles on catastrophic plans tend to be equal to out-of-pocket maximums; this means that coinsurance and deductibles will not factor into what you pay. Often you will pay a premium simply to get the same value for the care your insurer gets, and to know that you’ll never pay more than your out-of-pocket maximum in an emergency.
